Short Report
Isolated cold abscess of the thigh in an immunocompetent infant
Tropical Doctor 2014, Vol. 44(4) 221–222 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514524200 tdo.sagepub.com
Juhi Sharma1, Tanya Sharma2, Girish Chandra Bhatt3 and Ruchika Bhargava4
Abstract Isolated cold abscess of the thigh without active tuberculosis elsewhere in the body is a rare entity, and only a few cases have been reported in the literature. We report a case of isolated cold abscess of the thigh following DPT vaccination in an immunocompetent child. The association with DPT vaccination is intriguing and requires further research.
Keywords Isolated cold abscess, immunocompetent, tuberculosis
Introduction Isolated cold abscess of the thigh without active tuberculosis elsewhere in the body is a rare entity and only a few cases have been reported in the literature. We report a case of isolated cold abscess of the thigh following DPT vaccination in an immunocompetent child. The association with DPT vaccination is intriguing and requires further research.
Case report An 11-month-old male child presented to the outpatient department of a tertiary care hospital with a slowly progressive abscess on anterolateral aspect of thigh since the last 8 to 9 months. There was no history of fever, cough, loose stools, repeated infections or history of contact with tuberculosis in the family. The child was given BCG vacinnation and a scar was present. On reviewing the detailed past history, the parents admitted that the swelling appeared 8 days after the DPT vaccination which had gradually increased in size since then. On examination the child was afebrile, weighed 9.4 kg (between –1 SD and –2 SD as per World Health Organization growth charts) and had normal developmental milestones. The vitals of the child were normal and systemic examination revealed no abnormality. Local examination revealed a 2.5 2.2 cm swelling on the anterolateral aspect of the left thigh which was mobile, firm in consistency and non-tender without signs of inflammation. The parents contacted a local
physician when the boy was aged 3.5 months, for which he was prescribed oral antibiotics, but the swelling continued to increase in size despite being given 10 days of antibiotics. Investigations revealed: hemoglobin of 11 gm%, total leucocyte counts of 10,000 (with 36% polymorphs and 58% lymphocytes), normal erythrocyte sediment rate. A Mantoux test was positive (15 15 cm). X-ray of the left thigh revealed no features suggestive of osteomyelitis. Ultrasonography revealed an abscess 2.5 2.0 cm in size in the subcutaneous tissue not involving the muscle and without extension to the bony part. Fine needle aspiration of the child revealed viable and degenerated neutrophils, lymphocytes with occasional epithelioid cell granuloma and foreign body type of giant cells. Zeilh-Neelsnan (Z-N) staining showed numerous acid fast bacilli (AFB) and polymerase chain reaction (PCR) was positive for M. tuberculosis. Multiplex PCR essay was used to differentiate M. tuberculosis from non-tuberculous 1 Consultant Pathologist, Department of Pathology, Subharati Medical College, Meerut, Uttar Pradesh, India 2 Senior Resident, Department of Pathology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India 3 Assistant Professor, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India 4 Assistant Professor, Department of Pathology, LLRM Medical College, Meerut, Uttar Pradesh, India
Corresponding author: Dr Girish Chandra Bhatt, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, India. Email: [email protected], [email protected]
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mycobacterium. The child was started on a six-drug anti-tubercular treatment (ATT) (2 HRZE followed by 4 HR) after which the swelling subsided.
Discussion The index case was diagnosed as a case of tuberculous cold abscess of the thigh based on AFB positivity followed by PCR positivity for M. tuberculosis. Although tuberculosis involving the subcutaneous tissue from adjacent bony tissue is a known entity, isolated tuberculous abscess of the soft tissue without involvement of adjacent joints or bony areas in an immunocompetent child is rare.1 Previous reports have shown primary intramuscular tuberculous abscess of the thigh in children, which were presumed to be transmitted by syringes.2–4 Four cases were reported from one hospital in which a nurse with pulmonary tuberculosis had given multiple intramuscular injections to the affected children. Another report suggested transmission of tuberculous abscess of the thigh secondary to infected syringe from an infant with tuberculous gluteal abscess.2–4 However; in the index case we did not find any such history of reuse of contaminated syringes. Sterile abscess developing following DPT injection due to aluminium content of DPT vaccination is a known entity. One of the previous reports of cold abscess of the thigh in an infant 5 days after DPT vaccination was recently reported by Misra et al.,5 who speculated it as a rare association with intramuscular DPT vaccination. Another case was reported by Agrawal et al.6 in an 11-month-old infant following DPT vaccination. Another, differential diagnosis could be cutaneous infection due to M. ulcerans, also known as Buruli ulcer, which is a disabling and disfiguring disease that mainly affects children aged under 5 years in tropical and subtropical countries.7–9 M. ulcerans is an environmental mycobacteria commonly found in bodies of stagnant water, such as lakes and swamps. Although the exact mode of transmission is unclear, many reports suggested antecedent trauma at the site where the lesion later occurred. However, in this case PCR was positive for M. tuberculosis, implicating M. tuberculosis as the aetiological agent. Recently, PCR technique has been used to diagnose M. tuberculosis infection, which has added advantage of differentiate between M. tuberculosis from non-tuberculous mycobacterium.10
Thus, isolated cold abscess of thigh without active pulmonary, adjoining bone or joint tuberculosis should be kept in mind. Early therapy with systemic ATT is associated with a favourable outcome. Moreover, the formation of tuberculous abscess following DPT vaccination is intriguing and this association requires further research. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Puttick MPE, Stein HB, Chan RM, Elwood RK, How AR and Reid GD. Soft tissue tuberculosis: a series of 11 cases. J Rheumatol 1995; 22: 1321–1325. 2. Abdelwahab IF, Bianchi S, Martinoli C, Klein M and Hermann G. Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients: part II, tuberculous myositis, tuberculous bursitis, and tuberculous tenosynovites. Can Assoc Radiol J 2006; 57: 278–286. 3. Heycock JB and Noble TC. Four cases of syringe-transmitted tuberculosis. Tubercle 1961; 8: 23–26. 4. Brussaud DR and Canlorbe P. Vaccine associated tuberculosis in children. Arch Fr Pediatr 1951; 8: 49–50. 5. Mishra D, Mohta A and Arora P. Cold abscess of thigh in an infant. Kathmandu Univ Med J (KUMJ) 2013; 11: 86–87. 6. Agrawal A and Jain A. Tuberculous cold abscess. Indian J Pediatr 2007; 74: 771–773. 7. World Health Organization. Buruli ulcer disease. Mycobacterium ulcerans infection: an overview of reported cases globally. Wkly Epidemiol Rec 2004; 79: 194–200. 8. Portaels F, Johnson P and Meyers WM (eds). Buruli Ulcer. Diagnosis of Mycobacterium ulcerans Disease. Geneva: World Health Organization, 2001. 9. Janssens P, Pattyn SR, Meyers WM and Portaels F. Buruli ulcer: a historical overview with updating to 2005. Bull Seances Acad R Sci Outre Mer 2005; 51: 265–299. 10. Bhatt GC, Nandan D and Singh S. Isolated tubercuous liver abscess in imunocompetent children-Report of two cases. Pathog Glob Health 2013; 107: 35–37.
Downloaded from tdo.sagepub.com at Imperial College London Library on December 3, 2015
Isolated cold abscess of the thigh in an immunocompetent infant
Tropical Doctor 2014, Vol. 44(4) 221–222 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514524200 tdo.sagepub.com
Juhi Sharma1, Tanya Sharma2, Girish Chandra Bhatt3 and Ruchika Bhargava4
Abstract Isolated cold abscess of the thigh without active tuberculosis elsewhere in the body is a rare entity, and only a few cases have been reported in the literature. We report a case of isolated cold abscess of the thigh following DPT vaccination in an immunocompetent child. The association with DPT vaccination is intriguing and requires further research.
Keywords Isolated cold abscess, immunocompetent, tuberculosis
Introduction Isolated cold abscess of the thigh without active tuberculosis elsewhere in the body is a rare entity and only a few cases have been reported in the literature. We report a case of isolated cold abscess of the thigh following DPT vaccination in an immunocompetent child. The association with DPT vaccination is intriguing and requires further research.
Case report An 11-month-old male child presented to the outpatient department of a tertiary care hospital with a slowly progressive abscess on anterolateral aspect of thigh since the last 8 to 9 months. There was no history of fever, cough, loose stools, repeated infections or history of contact with tuberculosis in the family. The child was given BCG vacinnation and a scar was present. On reviewing the detailed past history, the parents admitted that the swelling appeared 8 days after the DPT vaccination which had gradually increased in size since then. On examination the child was afebrile, weighed 9.4 kg (between –1 SD and –2 SD as per World Health Organization growth charts) and had normal developmental milestones. The vitals of the child were normal and systemic examination revealed no abnormality. Local examination revealed a 2.5 2.2 cm swelling on the anterolateral aspect of the left thigh which was mobile, firm in consistency and non-tender without signs of inflammation. The parents contacted a local
physician when the boy was aged 3.5 months, for which he was prescribed oral antibiotics, but the swelling continued to increase in size despite being given 10 days of antibiotics. Investigations revealed: hemoglobin of 11 gm%, total leucocyte counts of 10,000 (with 36% polymorphs and 58% lymphocytes), normal erythrocyte sediment rate. A Mantoux test was positive (15 15 cm). X-ray of the left thigh revealed no features suggestive of osteomyelitis. Ultrasonography revealed an abscess 2.5 2.0 cm in size in the subcutaneous tissue not involving the muscle and without extension to the bony part. Fine needle aspiration of the child revealed viable and degenerated neutrophils, lymphocytes with occasional epithelioid cell granuloma and foreign body type of giant cells. Zeilh-Neelsnan (Z-N) staining showed numerous acid fast bacilli (AFB) and polymerase chain reaction (PCR) was positive for M. tuberculosis. Multiplex PCR essay was used to differentiate M. tuberculosis from non-tuberculous 1 Consultant Pathologist, Department of Pathology, Subharati Medical College, Meerut, Uttar Pradesh, India 2 Senior Resident, Department of Pathology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India 3 Assistant Professor, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India 4 Assistant Professor, Department of Pathology, LLRM Medical College, Meerut, Uttar Pradesh, India
Corresponding author: Dr Girish Chandra Bhatt, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, India. Email: [email protected], [email protected]
Downloaded from tdo.sagepub.com at Imperial College London Library on December 3, 2015
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Tropical Doctor 44(4)
mycobacterium. The child was started on a six-drug anti-tubercular treatment (ATT) (2 HRZE followed by 4 HR) after which the swelling subsided.
Discussion The index case was diagnosed as a case of tuberculous cold abscess of the thigh based on AFB positivity followed by PCR positivity for M. tuberculosis. Although tuberculosis involving the subcutaneous tissue from adjacent bony tissue is a known entity, isolated tuberculous abscess of the soft tissue without involvement of adjacent joints or bony areas in an immunocompetent child is rare.1 Previous reports have shown primary intramuscular tuberculous abscess of the thigh in children, which were presumed to be transmitted by syringes.2–4 Four cases were reported from one hospital in which a nurse with pulmonary tuberculosis had given multiple intramuscular injections to the affected children. Another report suggested transmission of tuberculous abscess of the thigh secondary to infected syringe from an infant with tuberculous gluteal abscess.2–4 However; in the index case we did not find any such history of reuse of contaminated syringes. Sterile abscess developing following DPT injection due to aluminium content of DPT vaccination is a known entity. One of the previous reports of cold abscess of the thigh in an infant 5 days after DPT vaccination was recently reported by Misra et al.,5 who speculated it as a rare association with intramuscular DPT vaccination. Another case was reported by Agrawal et al.6 in an 11-month-old infant following DPT vaccination. Another, differential diagnosis could be cutaneous infection due to M. ulcerans, also known as Buruli ulcer, which is a disabling and disfiguring disease that mainly affects children aged under 5 years in tropical and subtropical countries.7–9 M. ulcerans is an environmental mycobacteria commonly found in bodies of stagnant water, such as lakes and swamps. Although the exact mode of transmission is unclear, many reports suggested antecedent trauma at the site where the lesion later occurred. However, in this case PCR was positive for M. tuberculosis, implicating M. tuberculosis as the aetiological agent. Recently, PCR technique has been used to diagnose M. tuberculosis infection, which has added advantage of differentiate between M. tuberculosis from non-tuberculous mycobacterium.10
Thus, isolated cold abscess of thigh without active pulmonary, adjoining bone or joint tuberculosis should be kept in mind. Early therapy with systemic ATT is associated with a favourable outcome. Moreover, the formation of tuberculous abscess following DPT vaccination is intriguing and this association requires further research. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Puttick MPE, Stein HB, Chan RM, Elwood RK, How AR and Reid GD. Soft tissue tuberculosis: a series of 11 cases. J Rheumatol 1995; 22: 1321–1325. 2. Abdelwahab IF, Bianchi S, Martinoli C, Klein M and Hermann G. Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients: part II, tuberculous myositis, tuberculous bursitis, and tuberculous tenosynovites. Can Assoc Radiol J 2006; 57: 278–286. 3. Heycock JB and Noble TC. Four cases of syringe-transmitted tuberculosis. Tubercle 1961; 8: 23–26. 4. Brussaud DR and Canlorbe P. Vaccine associated tuberculosis in children. Arch Fr Pediatr 1951; 8: 49–50. 5. Mishra D, Mohta A and Arora P. Cold abscess of thigh in an infant. Kathmandu Univ Med J (KUMJ) 2013; 11: 86–87. 6. Agrawal A and Jain A. Tuberculous cold abscess. Indian J Pediatr 2007; 74: 771–773. 7. World Health Organization. Buruli ulcer disease. Mycobacterium ulcerans infection: an overview of reported cases globally. Wkly Epidemiol Rec 2004; 79: 194–200. 8. Portaels F, Johnson P and Meyers WM (eds). Buruli Ulcer. Diagnosis of Mycobacterium ulcerans Disease. Geneva: World Health Organization, 2001. 9. Janssens P, Pattyn SR, Meyers WM and Portaels F. Buruli ulcer: a historical overview with updating to 2005. Bull Seances Acad R Sci Outre Mer 2005; 51: 265–299. 10. Bhatt GC, Nandan D and Singh S. Isolated tubercuous liver abscess in imunocompetent children-Report of two cases. Pathog Glob Health 2013; 107: 35–37.
Downloaded from tdo.sagepub.com at Imperial College London Library on December 3, 2015
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